Healthcare Provider Details

I. General information

NPI: 1487362919
Provider Name (Legal Business Name): MAXX LIFE HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 PENNSYLVANIA AVE STE B
MCDONOUGH GA
30253-9112
US

IV. Provider business mailing address

1540 PENNSYLVANIA AVE STE B
MCDONOUGH GA
30253-9112
US

V. Phone/Fax

Practice location:
  • Phone: 404-932-7183
  • Fax:
Mailing address:
  • Phone: 404-932-7183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARIA WALLER
Title or Position: MANAGING MEMBER
Credential:
Phone: 404-932-7183